Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Vaccination Consent Form
Your information
Patient Full Name *
Date of Birth
____ / ____ / ________
Vaccine(s) Requested
Allergies to Vaccine Components
Currently Pregnant or Immunocompromised
Recent Illness or Fever
Additional details
Previous Adverse Reaction to Vaccines
VIS Received and Reviewed
Guardian Name (if minor)
Consent to Vaccinate
Patient or Guardian Signature
Date
Date of Consent
____ / ____ / ________
Vaccination Consent Form template from formisoft.com. formisoft.com/intake-templates/vaccination-consent